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Xu et al. Plast Aesthet Res 2022;9:33 https://dx.doi.org/10.20517/2347-9264.2021.116 Page 9 of 17

small differences in most outcomes had they undergone amputation [98,99] . Importantly, mobility scores
would have been significantly improved for amputation [98,99] . No strong evidence currently exists for
replantation or VCA of the lower extremity.

Inherent differences in the circumstances surrounding limb salvage and replantation versus
allotransplantation may favor the latter in terms of patient benefit. Limb salvage and replantation make use
of the injured extremity in acute, urgent operations that must occur shortly after trauma. Consequently,
they involve little predictability, minimal preoperative planning, and greater ischemia time. In VCA, the
allograft tissues are less damaged, the procedure is better controlled given its more elective nature, and the
recipient is more clinically stable at the time of surgery and able to begin rehabilitation earlier .
[37]
Importantly, VCA of the lower extremity is not mutually exclusive from limb salvage, replantation or
amputation, as VCA could still be performed in the future if another option is initially pursued.

As discussed above, the argument for VCA involves its recovery of sensory and motor function, decreased
disability, and psychosocial benefits - although existing data is from upper extremity, not lower extremity
VCA. Both limb salvage and replantation procedures also offer the key benefit of restoration of sensation,
but hand transplantation has demonstrated higher rates of recovery for tactile and discriminative sensibility
(80%-90% vs. 30%-60% for replantation) [20,100] . Transplanted hands also exhibit finer two-point
discrimination than replanted hands, although this measure is not an essential goal for the lower
extremity [28,101,102] . Otherwise, replants have shown superior strength, perhaps due to greater muscle atrophy
in transplant recipients secondary to extended time between limb loss and VCA, but lesser recovery of
intrinsic muscle use [28,103] . Further, salvage and replantation are associated with a higher degree of scarring
and a greater risk of unequal lower extremity lengths due to bone-shortening from the inciting
trauma [104,105] . VCA has the benefit of having excess tissues available for procurement to maximize cosmetic
results. Per overall quality of life, limb salvage has demonstrated psychological results near equivalent to
amputation, with substantial postoperative rates of depression, anxiety, substance abuse, and suicidal
ideation . In contrast, replantation and allotransplantation have reduced concerns related to body image,
[96]
independence, and social reintegration [106,107] . Patients undergoing both procedures have been able to resume
suitable work, with transplant recipients reporting higher satisfaction [108,109] . It must also be mentioned that
while physical rehabilitation is required for all three options, VCA was initially thought to require the
additional burden of cognitive therapy to gain control of the allograft. Yet, evidence suggests that this may
not be necessary, as immediate cortical integration has been demonstrated in upper extremity VCA
recipients long after amputation, and a substantial concern has been removed from the argument against
allotransplantation .
[110]
With the use of autologous tissues for salvage and replantation, the harms related to allogeneic tissue are no
longer relevant. There is no requirement for long-term immunosuppression and thus no assumption of its
associated risks. However, limb salvage does require extensive debridement, fasciotomies, revascularization,
and fixation and is known to be associated with a high rate of complications, including infection,
thrombosis, necrosis, impaired bone healing, and the need for secondary procedures [111,112] . It must be noted
that lower extremity replantation has been associated with a high rate of complications as well, with up to
86% of patients requiring secondary surgeries and a low rate of autograft survival at 45%, albeit available
data is sparse . Using an individual’s own tissues also precludes the development of psychosocial issues
[85]
with limb assimilation and body integrity that can cause critical consequences for VCA of the extremity.
Finally, at present, the acceptance and continued practice of limb salvage and replantation means less
uncertainty and more access to long-term data relative to allotransplantation.